OSP petition form & instructions - NC
PLEASE PRINT CLEARLY OR TYPE
|STATE OF NORTH CAROLINA |IN THE OFFICE OF |
|COUNTY OF (1)__________________________________ |ADMINISTRATIVE HEARINGS |
|(2)___________________________________________________ |) | |
| |) | |
|_____________________________________________________ |) | |
|(your name) PETITIONER, |) | |
| |) |PETITION |
|v. |) |FOR A |
| |) |CONTESTED CASE HEARING |
|(3)___________________________________________________ |) |(N.C. Gen. Stat. § 126) |
| |) | |
|_____________________________________________________ |) | |
| RESPONDENT. |) | |
|(The State agency or board about which you are complaining) |) | |
I hereby ask for a contested case hearing as provided for by North Carolina General Statutes §§ 126-34.01, 126-34.02 and 126-35 because the Respondent has acted as follows:
(4) MY APPEAL IS BASED ON: (check all that apply)
* _____discharge without just cause _____suspension without just cause _____demotion without just cause
_____failure to receive priority consideration _____other (explain)_______________________________________________
* The following occurred due to discrimination and/or retaliation for opposition to alleged discrimination:
| _____employment | | _____demotion |
| _____promotion | | _____layoff |
| _____training |AND/OR | _____termination |
| _____transfer | | |
_____other (explain) _________________________________________________________________________________________
* If your appeal is based upon alleged discrimination and/or retaliation for opposition to alleged discrimination, you must specify the type of discrimination: _____ Race _____ Religion _____Color _____ Genetic Information _____ National Origin
_____ Sex _____ Age _____ Disability _____ Political Affiliation
(5) Briefly state facts showing how you believe you have been harmed by the State/local agency or board:
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
(If more space is needed, attach additional pages.)
Pay grade: ________________ Months of continuous State employment: _______ Job title:______________________________
If applicant, I applied for:__________________________________________________________________________________________
(6) Date: ______________________________ (7) Your phone number: ( )_________________________________________________
(8) Print your full mailing address: ____________________________________________________________________________________
(street address/p.o. box) (city) (state) (zip)
Print your e-mail address: ____________________________________________________________________________________
(9) Print your name:_____________________________ (10) Your signature: _____________________________________________
You must mail or deliver a COPY of this Petition to the agency or board named on line (3) of this form. You should contact the agency or board to determine the name of the person to be served.
CERTIFICATE OF SERVICE
I certify that this Petition has been served on the agency or board named below by depositing a copy of it with the United States Postal Service with sufficient postage affixed OR by delivering it to the named agency or board:
(11) _________________________________________ (12) _____________________________________________________
(name of person served) (agency or board listed on line 3)
(13) _________________________________________________________________________________________________________
(address)
(14) This the _____ day of _________________, 20_____ (15) _____________________________________________________
(your signature)
When you have completed this form, you MUST mail or deliver the ORIGINAL to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6700.
Filing a Petition for a Contested Case Hearing does not constitute the filing of a discrimination charge with the EEOC or the Civil Rights Division of the Office of Administrative Hearings. Should you decide to file such a charge, you should contact the Office of Administrative Hearings, Civil Rights Division or the EEOC office nearest you; EEOC offices are located in the following cities: Charlotte, Raleigh, and Greensboro.
This box for OAH use only.
| | |
|Amount Paid $__________ | Indigent (must complete form HOI ) |
| | |
| Cash – receipt number _____________________________ | Mandated federal cause of action |
| | |
| Money Order Certified Check Attorney Trust Account | |
| |Received by:___________________________________________ |
|Check number_____________________________________ | |
INSTRUCTIONS FOR FORM H-06A (personnel)
“PETITION FOR A CONTESTED CASE” AND “CERTIFICATE OF SERVICE”
PLEASE PRINT CLEARLY OR TYPE
FILL IN BLANKS:
Fill in your county of residence on line (1), print your name on line (2), and the name of the agency or board about which you are complaining on line (3). Check all of the items that apply in section (4), and briefly state the facts about your case on line (5); you may add additional pages if necessary. Fill in the subsequent blanks (pay grade, months of employment, etc.), enter the date on line (6), your telephone number on line (7), your full mailing and e-mail addresses on line (8), print your name on line (9), and sign your name on line (10).
CERTIFICATE OF SERVICE:
You must mail or deliver a copy of your completed petition to the agency or board involved and complete the “certificate of service” section on your petition, entering the name of the person to whom you mailed or delivered the petition on line (11). You should contact the agency or board to determine the name of the person to be served. Print the name of the agency/board involved on line (12), the address of the agency/board on line (13), the date on line (14), and sign your name on line (15).
FILING FEE
Filing fees can be paid be either, cash, money order, certified check or checks drawn on attorney trust accounts. A $20.00 fee must be paid when the petition is filed. Checks should be made payable to the Office of Administrative Hearings.
FILING YOUR PETITION WITH THE OFFICE OF ADMINISTRATIVE HEARINGS:
Your contested case will commence as soon as you file your completed original petition, properly signed, and the appropriate filing fee, with the Office of Administrative Hearings. Below are the mailing and physical addresses:
If you mail this form, the case commences when it is received and filed in this office.
|Office of Administrative Hearings |Office of Administrative Hearings |
|6714 Mail Service Center |1711 New Hope Church Road |
|Raleigh NC 27699-6700 |Raleigh, NC 27609-6285 |
You may file your petition by fax during normal business hours by faxing the petition to the Clerk's Office at (919) 431-3100.
You may file your petition by electronic mail by an attached file either in PDF format or a document that is compatible with or convertible to the most recent version of Word for Windows by sending the electronic transmission to oah.clerks@oah.. Electronic mail without attached file shall not constitute a valid filing.
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